How do you approach an acute non-LVO stroke with a known large core (>70 mL, 0-5 ASPECTS, or other metric)?

As with any treatment, you have to weigh the individual patient characteristics and overall risks vs. benefits. If there is no LVO, then the question is whether to pursue thrombolysis. In the extended window, thrombolysis was really only helpful in very small core patients, so if the patient is beyond the 4.5-hour window, I would not consider thrombolysis in large core patients. Within the 4.5-hour window, I would make sure to do a very detailed analysis of the individual risks and benefits for ...

I would offer tenecteplase to patients at 0-4.5 hours, but with the warning that the risk of hemorrhage is likely higher, and that while thrombolysis may improve the outcome, it will still likely be disabling. Beyond 4.5 hours, I would be extremely cautious, not recommend the treatment, but would discuss the option with the patient and family.